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 Table of Contents  
Year : 2018  |  Volume : 51  |  Issue : 5  |  Page : 175-179

Chronic periodontal disease correlated with sezual function in young males

1 Department of Surgery, Division of Urology, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
2 Department of Nutritional Science, Fu Jen Catholic University, Taipei, Taiwan
3 National Defense Medical Center, School of Public Health, Taipei, Taiwan

Date of Submission03-May-2017
Date of Decision18-Aug-2017
Date of Acceptance21-Feb-2018
Date of Web Publication17-Oct-2018

Correspondence Address:
Dr. Chih-Wei Tsao
Department of Surgery, Division of Urology, National Defense Medical Center, Tri-Service General Hospital, No. 325, Section 2, Cheng-Gung Road, Neihu District, Taipei 114
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/fjs.fjs_72_17

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Background: In this study, we aimed to identify the association between chronic periodontal disease (CPD) and erectile dysfunction (ED) in a large young population.
Patients and Methods: Totally 2191 male participants aged 18–28 years attended the Army Training Center in Taiwan between August 2012 and May 2013. All 1932 included participants filled in the International Index of Erectile Function-5 (IIEF-5) questionnaire and received a comprehensive dental examination to classify whether CPD.
Results: There was a statistically significant correlation between the presence of ED and CPD (P < 0.001). Multivariate logistic regression analysis indicated that men with CPD were 1.6 (95% confidence interval = 1.280–2.009, P < 0.001) times more likely to have ED than men without CPD after adjusting confounders.
Conclusion: This study demonstrates a link between ED and CPD, and it may be attributed to a combination of psychogenic and organic etiologies, such as systemic inflammation, oxidative stress, and endothelial dysfunction. This study highlights the significance of oral health, which may take a role in sexual function, even in young males. In clinical practice, more comprehensive management strategies to address participants with ED and CPD need to be investigated.

Keywords: Chronic periodontal disease, erectile dysfunction, large population, psychological effect, young males

How to cite this article:
Chou MH, Liu CY, Yang MH, Chou YC, Wu ST, Cha TL, Tsao CW. Chronic periodontal disease correlated with sezual function in young males. Formos J Surg 2018;51:175-9

How to cite this URL:
Chou MH, Liu CY, Yang MH, Chou YC, Wu ST, Cha TL, Tsao CW. Chronic periodontal disease correlated with sezual function in young males. Formos J Surg [serial online] 2018 [cited 2021 Apr 18];51:175-9. Available from: https://www.e-fjs.org/text.asp?2018/51/5/175/243585

  Introduction Top

Erectile dysfunction (ED) is defined as the inability to attain and/or maintain an erection sufficient for satisfactory sexual performance.[1] The incidence of ED in young males may be underestimated due to reporting bias, but ED in a young man adversely influences his well-being and intimate relationships.[2] Previous studies showing common predisposing factors for ED and cardiovascular disease, such as obesity, cigarette smoking, and low physical activity status, suggest that ED may be a harbinger of subsequent vascular illness. Early lifestyle modifications to reverse the impact of risk factors on ED and cardiovascular disease are highly recommended.[3],[4]

Chronic periodontal disease (CPD) is an inflammatory disease that is common in adults and is characterized by the loss of both the attachment of the periodontal ligament and the bony support of the tooth. It most often accompanies the inflammation of the gingival tissues.[1] CPD manifests as pain, easy bleeding, pyorrhea, pocket formation, and periodontitis.[5] Periodontal infections have a direct effect on the vasculature and act as a source of systemic inflammation, which in turn accelerate the atherosclerotic process.[6] Emerging evidence suggests that periodontal therapy may improve endothelial function by decreasing the level of systemic biomarkers and may attenuate the risk of cardiovascular disease.[6],[7],[8],[9],[10]

Recent studies[1],[5],[11],[12] have demonstrated that ED and CPD may share common pathophysiological factors such as systemic inflammation, oxidative stress, and endothelial dysfunction. We sought to determine the risk associated with ED in individuals with and without CPD in a general population of young males in this cross-sectional study.

  Materials and Methods Top


An experienced urologist and a dentist evaluated 2191 young military males attending the Army Training Center between August 2012 and May 2013. Two hundred and fifty-nine participants were excluded because they had comorbidities or psychological disorders other than ED, did not agree to complete the International Index of Erectile Function-5 (IIEF-5) questionnaire, or had not engaged in sexual intercourse in the past 6 months. Written informed consents were completed from all participants, and the study protocol was approved by the Ethics Committees of Tri-Service General Hospital. A total of 1932 participants (aged 18–28 years, mean age: 21.65 ± 2.609 years) provided informed consent and remained as participants in the study. All participants underwent history taking, physical examinations, the dental examinations to evaluate the presence of CPD and filled in the IIEF-5 questionnaire. The dentist was blinded to the IIEF-5 questionnaire scores of the participants during the dental examinations.

International Index of Erectile Function-5 questionnaire

The IIEF-5 questionnaire was used to assess ED and assess its severity. The questionnaire comprises five items: erectile confidence, maintenance ability, maintenance frequency, erection firmness, and intercourse satisfaction. Each is rated on a 6-point scale from 0 to 5, except for one item (erectile confidence), which is rated on a 5-point scale from 1 to 5. The final score, ranging from 1 to 25, is calculated by summing individual scores. Scores above 21 represent normal erectile function and scores at or below this cutoff represent ED. ED severity is classified into five categories: severe ED (1–7), moderate ED (8–11), moderate-to-mild ED (12–16), mild ED (17–21), and no ED (22–25).

Statistical analysis

Student's t-test and Chi-square test were used to compare the variables of ED and non-ED males. The variables that showed significant differences on univariate analysis were included in the multivariate model to evaluate the risk of ED. We performed multivariate logistic regression analyses and estimated odds ratios (ORs) and 95% confidence intervals (CIs) for the association between the potential risk factor levels and ED risk. Significance was defined as P < 0.05 for all tests. Data were analyzed using IBM SPSS 22.0 (IBM SPSS Inc., Chicago, IL).

Ethical approval

The study was conducted in accordance with the Declaration of Helsinki and was approved by the local ethics committee of the institute. Informed written consent was obtained from all patients prior to their enrollment in this study.

  Results Top

Overall, 1932 participants completed the IIEF-5 questionnaire, history taking, and dental examinations at the Army Training Center. The mean age was 21.78 years (±2.57) for men with ED and 21.60 years (±2.62) for men without ED (P = 0.205). [Table 1] presents the clinical characteristics and demographic distribution of men with/without ED. There were no significant differences in education level, cigarette smoking, number of masturbation times per week, or the presence of varicoceles between men with/without ED. Among the men included, 484 (25.1%) had mild ED according to the IIEF-5 questionnaire scores (≤21), and 517 (26.8%) had CPD according to the dental examinations.
Table 1: Clinical characteristics and demographic distribution of men with/without erectile dysfunction

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In the present study, IIEF-5 scores were associated with the existence of CPD. Further analysis of the individual items showed that the existence of CPD was significantly inversely related to the 2nd (maintenance ability), 4th (erection firmness), and 5th (intercourse satisfaction) items of IIEF-5. However, there was no significant difference in erection confidence between the CPD and non-CPD groups [P = 0.251, in [Table 2].
Table 2: International Index of Erectile Function-1~5 distribution of chronic periodontal disease patients

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The OR of CPD and other variables in terms of ED are presented in [Table 3]. In total, 26.8% of the 1932 participants were diagnosed with CPD. The prevalence of CPD was 34.3% and 24.2% for men with ED and men without ED, respectively (P < 0.001). Similarly, multivariate logistic regression analysis also revealed that men with CPD were 1.6 (95% CI = 1.280–2.009, P < 0.001) times more likely to have ED than men without CPD after adjusting for body mass index (BMI), cigarette smoking, and age. Moreover, the risk of ED differs significantly by BMI (95% CI = 1.014–1.155, P = 0.017). In contrast, we also found an inverse association between cigarette smoking and ED: the risk of ED in smokers was 30% lower than that in nonsmokers (95% CI = 0.500–0.984, P = 0.004).
Table 3: Risk factors for erectile dysfunction

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  Discussion Top

To the best of our knowledge, the present study was the first cross-sectional study in Taiwan to focus on the correlation between CPD and ED in young males with no systemic health conditions. History taking, comprehensive dental examinations, and IIEF-5 questionnaires were all carried out at an Army Training Center. It was interesting to note that participants with CPD had an increased risk of ED.

Epidemiologic studies have shown that several comorbid factors, including diabetes mellitus, dyslipidemia, hypertension, and coronary artery diseases, are independently and significantly related to ED.[13],[14],[15] Since the participants in our study were young and had undergone army selection and those with comorbidities were excluded, we can presume that comorbidities had no effects to process ED in the study. After adjusting for BMI, smoking, and age, a statistically significant correlation existed between the incidence of ED and the presence of CPD.

Local infections associated with CPD may induce systemic inflammation and cause endothelial dysfunction that may progress to atherosclerosis in small vessels such as the penile vasculature and later in large arteries such as the coronary arteries.[16],[17] ED can be an early sign of devastating cardiovascular events, and this requires further exploration.

Zuo et al.[5] reported that there was no significant ultrastructural change in the corpus cavernosum of rats with periodontitis, but they did have a decreased expression of the endothelial nitric oxide synthase protein. This implies that periodontitis chiefly impairs the function of endothelial cells rather than their structure.

Dental extraction or treatment of CPD seems to attenuate endothelial injury by alleviating periodontitis-related inflammation, which further halts the process of ED. The significantly lower OR for ED in patients with CPD who have undergone dental extraction supports this theory.[12]

Still, other hypotheses should be postulated. In our study, erectile confidence was not related to the existence of CPD. This indicates that participants with CPD were capable of achieving a rigid erection but failed to perform sexually with their partners during intercourse. Foul odors, unpleasant psychological status, and diet alteration[12] caused by CPD may also affect an individual's sex life. We believe that ED may result from a combination of vasculogenic and nonvasculogenic etiologies of CPD.

We found the risk of ED slightly increased by higher BMI, in agreement with a comparable series described previously.[18] Based on these observations, it seems reasonable to consider obesity showed a strong correlation with ED, even in young males.

Despite the well-known detrimental effects of heavy smoking, in our study, this was not found to be an independent risk factor of ED. However, we did not obtain clear data on the amount, frequency, and duration of cigarette consumption. Smoking may relieve the stress or anxiety, which may be a beneficial factor to the erectile function in young males. Another possible explanation for this anomalous finding is that young males who smoke cigarettes are psychologically more confident in their sexual satisfaction. There is no denying that cigarette consumption causes accumulative harm on impotence and general health.

There were several limitations in this study, for example: (1) the IIEF-5 questionnaire was unable to differentiate between potential etiologies causing ED. (2) The severity of periodontitis was not quantified and presented in this study. (3) Although participants with psychological disorders had been excluded from the study, we did not provide psychological assessment such as Hamilton Depression Scale or Beck Depression Inventory; psychological factors such as stress, anxiety, and insomnia act as potential contributors to ED. (4) ED was more prevalent in young males with chronic prostatitis/chronic pelvic pain syndrome, which should be listed as a potential variable for further analysis.[19] (5) Further information on participants could be included within the statistical analysis, in addition to their ages, smoking habits, obesity levels, and comorbidities.

In this study, we found that the incidence of ED in young males with CPD was higher than those without CPD, even after adjustment for age, cigarette smoking, and BMI. A link between ED and CPD was demonstrated in the study and may be attributed to both psychogenic and organic etiologies, such as systemic inflammation, oxidative stress, and endothelial dysfunction. Urologists should consider the significance of oral hygiene and the potential connections between ED, dental conditions, and cardiovascular diseases when treating male sexual function. Further scientific investigations to prove the causal relationship between ED and CPD should be encouraged in the future. In conclusion, males should be educated on the hypothetical association between oral hygiene and sexual life, even in younger populations.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sharma A, Pradeep AR, Raju PA. Association between chronic periodontitis and vasculogenic erectile dysfunction. J Periodontol 2011;82:1665-9.  Back to cited text no. 1
Cohen SD. The challenge of erectile dysfunction management in the young man. Curr Urol Rep 2015;16:84.  Back to cited text no. 2
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Nicolosi A, Moreira ED Jr., Shirai M, Bin Mohd Tambi MI, Glasser DB. Epidemiology of erectile dysfunction in four countries: Cross-national study of the prevalence and correlates of erectile dysfunction. Urology 2003;61:201-6.  Back to cited text no. 4
Zuo Z, Jiang J, Jiang R, Chen F, Liu J, Yang H, et al. Effect of periodontitis on erectile function and its possible mechanism. J Sex Med 2011;8:2598-605.  Back to cited text no. 5
Tonetti MS. Periodontitis and risk for atherosclerosis: An update on intervention trials. J Clin Periodontol 2009;36 Suppl 10:15-9.  Back to cited text no. 6
Higashi Y, Goto C, Jitsuiki D, Umemura T, Nishioka K, Hidaka T, et al. Periodontal infection is associated with endothelial dysfunction in healthy subjects and hypertensive patients. Hypertension 2008;51:446-53.  Back to cited text no. 7
Li X, Tse HF, Yiu KH, Jia N, Chen H, Li LS, et al. Increased levels of circulating endothelial progenitor cells in subjects with moderate to severe chronic periodontitis. J Clin Periodontol 2009;36:933-9.  Back to cited text no. 8
Li X, Tse HF, Jin LJ. Novel endothelial biomarkers: Implications for periodontal disease and CVD. J Dent Res 2011a; 90:1062-9.  Back to cited text no. 9
Li X, Tse HF, Yiu KH, Li LS, Jin L. Effect of periodontal treatment on circulating CD34(+) cells and peripheral vascular endothelial function: A randomized controlled trial. J Clin Periodontol 2011b; 38:148-56.  Back to cited text no. 10
Keller JJ, Chung SD, Lin HC. A nationwide population-based study on the association between chronic periodontitis and erectile dysfunction. J Clin Periodontol 2012;39:507-12.  Back to cited text no. 11
Tsao CW, Liu CY, Cha TL, Wu ST, Chen SC, Hsu CY, et al. Exploration of the association between chronic periodontal disease and erectile dysfunction from a population-based view point. Andrologia 2015;47:513-8.  Back to cited text no. 12
Nikolaidou B, Nouris C, Lazaridis A, Sampanis C, Doumas M. Diabetes mellitus and erectile dysfunction. In: Erectile Dysfunction in Hypertension and Cardiovascular Disease. Springer; 2015. p. 119-28.  Back to cited text no. 13
Rosen RC, Fisher WA, Eardley I, Niederberger C, Nadel A, Sand M, et al. The multinational men's attitudes to life events and sexuality (MALES) study: I. Prevalence of erectile dysfunction and related health concerns in the general population. Curr Med Res Opin 2004;20:607-17.  Back to cited text no. 14
Seftel AD, Sun P, Swindle R. The prevalence of hypertension, hyperlipidemia, diabetes mellitus and depression in men with erectile dysfunction. J Urol 2004;171:2341-5.  Back to cited text no. 15
Matsumoto S, Matsuda M, Takekawa M, Okada M, Hashizume K, Wada N, et al. Association of ED with chronic periodontal disease. Int J Impot Res 2014;26:13-5.  Back to cited text no. 16
Zadik Y, Bechor R, Galor S, Justo D, Heruti RJ. Erectile dysfunction might be associated with chronic periodontal disease: Two ends of the cardiovascular spectrum. J Sex Med 2009;6:1111-6.  Back to cited text no. 17
Tsao CW, Hsu CY, Chou YC, Wu ST, Sun GH, Yu DS, et al. Is obesity correlated with sexual function in young men? J Androl 2009;30:275-9.  Back to cited text no. 18
Shoskes DA. The challenge of erectile dysfunction in the man with chronic prostatitis/chronic pelvic pain syndrome. Curr Urol Rep 2012;13:263-7.  Back to cited text no. 19


  [Table 1], [Table 2], [Table 3]

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